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Trimmel et al.

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine


(2018) 26:38
https://doi.org/10.1186/s13049-018-0504-3

ORIGINAL RESEARCH Open Access

Emergency management of patients with


ST-segment elevation myocardial infarction
in Eastern Austria: a descriptive quality
control study
Helmut Trimmel1,2,4* , Thomas Bayer1, Wolfgang Schreiber4, Wolfgang G. Voelckel5,6,7 and Lukas Fiedler3

Abstract
Background: Myocardial infarction is a time-critical condition and its outcome is determined by appropriate
emergency care. Thus we assessed the efficacy of a supra-regional ST-segment elevation myocardial infarction
(STEMI) network in Easternern Austria.
Methods: The Eastern Austrian STEMI network serves a population of approx. 766.000 inhabitants within a region of
4186 km2. Established in 2007, it now comprises 20 pre-hospital emergency medical service (EMS) units (10 of these
physician-staffed), 4 hospitals and 3 cardiac intervention centres. Treatment guidelines were updated in 2012 and
documentation within a web-based STEMI registry became mandatory. For this retrospective qualitative control
study, data from February 2012–April 2015 was assessed.
Results: A total of 416 STEMI cases were documented, and 99% were identified by EMS within 6 (4.0–8.0) minutes
after arrival. Median time loss between onset of pain and EMS call was 54 (20–135) minutes; response, pre-hospital
and door-to-balloon times were 14 (10–20), 46 (37–59) and 45 (32–66) minutes, respectively. When general
practitioners were involved, time between onset of pain and balloon inflation significantly increased from 180
(135–254) to 218 (155–348) minutes (p < .001). A pre-hospital time < 30 min was achieved in 25.8% of all patients
during the day vs. 11.6% during the night (p < .001). Three hundred forty-five patients (83%) were subjected to
primary percutaneous coronary intervention (PPCI), and 6.5% were thrombolysed by EMS. Pre-hospital complication
rate was 18% (witnessed cardiac arrest 7%, threatening arrhythmias 6%, cardiogenic shock 5%). Twenty-four hours
and hospital mortality rate were 1.2 and 2.8%, respectively.
Discussion: Optimal patient care and subsequently outcome of STEMI is strongly determined by a short patient-
decision time to call EMS and by the first medical contact to balloon time (FMCBT). Supra-regional networks are key
in order to increase the efficacy and efficiency of health care. The goal of 120 min FMCBT was achieved in 78% of
our patients immediately managed by EMS, thus indicating room for improvement.
(Continued on next page)

* Correspondence: Helmut.Trimmel@meduniwien.ac.at
1
Department of Anesthesiology, Emergency and Critical Care Medicine,
General Hospital Wiener Neustadt, Corvinusring 3-5, A 2700 Wiener Neustadt,
Austria
2
Karl Landsteiner Institute of Emergency Medicine, General Hospital Wiener
Neustadt, Corvinusring 3-5, A 2700 Wiener Neustadt, Austria
Full list of author information is available at the end of the article

© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Trimmel et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2018) 26:38 Page 2 of 8

(Continued from previous page)


Conclusion: In conclusion, results from the Eastern Austrian STEMI network shed light on the necessity of
increasing patient awareness in order to minimize any time loss derived by delayed EMS calls. Involvement of
family physicians resulted in prolonged FMCBT. A stronger utilization of rescue helicopters could further improve
the efficacy of this supra-regional network. Nevertheless PPCI rates, time intervals and outcome rates compare well
with international benchmarks.
Keywords: ST-segment elevation myocardial infarction, Network, Time intervals, Pre-hospital management, Quality
control study

Background units (8 of them physician-staffed), 2 helicopter emer-


Acute, non-traumatic chest pain is one of the leading gency medical services (HEMS), 4 hospitals and 3 car-
causes for EMS activation [1] and 15% of all missions diac intervention centres with rotating 24/7 service.
are triggered by cardiac events [2]. In Austria, 20.000 pa- Transport distances to the PCI centre on duty may be
tients per year suffer from an acute coronary syndrome up to 90 km. Whenever a STEMI is diagnosed, high pri-
(ACS) [3] comprising unstable angina pectoris, Non-ST- ority is given to the time intervals and pre-hospital
segment elevation myocardial infarction (NSTEMI), and decision-making according to ESC guidelines [9] (Fig. 1).
ST-segment elevation myocardial infarction (STEMI). In All guidelines and recommendations are re-assessed an-
order to assess the quality of emergency medical service nually. Treatment and transport guidelines were updated
(EMS) care, ACS is one of four accepted tracer diagno- in 2012. Based on current literature [11], the new platelet
ses where appropriate management will most likely inhibitor Ticagrelor was added to the standard antithrom-
affect outcome [4–6]. Since pre-hospital mortality of botic medication comprising unfractionated heparin and
STEMI patients is still high, timely identification and salicylic acid (Fig. 2). Documentation in a web-based
intervention is crucial [7, 8]. The European Society of STEMI registry (Survey Monkey®, Palo Alto, CA, USA) has
Cardiology recommends that STEMI patients should be been mandatory since 2012. Each data set must be com-
identified within 10 min after first medical contact, and, pleted when the patient is discharged from hospital, in
whenever possible, primary percutaneous coronary inter- order to document serious adverse events and outcome.
vention (PPCI) should be initiated in less than 120 min. For this retrospective qualitative control study, data
Any delay caused by a deferred EMS dispatch, any in- from February 2012–April 2015 was assessed. The study
volvement of non-PCI-capable hospitals and emergency was approved by the ethical committee of the Medical
departments should be avoided [9, 10]. In order to University of Vienna (EK-ID number 1116/2016). Data
match these requirements and to optimize pre-hospital obtained was handled according to current data protec-
medication, local STEMI networks should be tion guidelines.
established. Data was analysed employing MS Excel (Microsoft, Red-
The Eastern Austrian STEMI Network was founded in mond, WA, USA) and SPSS 23 (IBM, NY, USA) and is
2007. Strict adherence to the consensus-based STEMI presented as median and interquartile range or mean ±
network treatment guidelines is obligatory for all EMS standard deviation whenever appropriate. For statistical
involved. Guidelines were revised in 2012, and Clopido- tests ANOVA (analysis of variance), Kruskal-Wallis-Test
grel was replaced by Ticagrelor as first-line oral anti- or Chi2-Test, and Spearman correlation were used. A
coagulant to be administered in combination with p value < 0.05 was considered indicative for significance.
intravenous unfractionated heparin and salicylic acid.
In order to evaluate the efficiency and efficacy of our Results
STEMI Network, we sought to assess all time intervals During the study period, 416 cases were classified as
indicative for outcome, survival rates and possible STEMI in the pre-hospital setting, and subsequently
complications. transported to one of the 3 PCI centres. In 4 cases the pre-
hospital assumed STEMI was not confirmed in hospital,
Methods and patients were diagnosed to suffer from Tako-Tsubo
The Eastern Austrian STEMI Network works to cardiomyopathy, pulmonary embolism or anaemia-driven
optimize emergency medical care of patients suffering cardiac ischemia, respectively.
from ACS across state boarders and to ensure the same
level of therapy for all patients. The network serves a Primary findings
population of approx. 766,000 inhabitants within a re- Patients were predominately male (73.8%) and younger
gion of 4186 km2. It now comprises 20 ground EMS (mean male vs. female age 61.7 ± 12.3 vs. 69.6 ± 13.9 years).
Trimmel et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2018) 26:38 Page 3 of 8

Fig. 1 Prehospital reperfusion strategies (ESC Guidelines 2017). Legend: Modes of patient presentation, components of ischaemia time and
flowchart for reperfusion strategy selection. EMS = Emergency Medical System; FMC = First Medical Contact; PCI = Percutaneous Coronary
Intervention; STEMI = ST-segment elevation myocardial infarction. The recommended mode of patient presentation is by alerting the EMS (call
national emergency number: 112 or similar number according to region). When STEMI diagnosis is made in the out-of-hospital setting (via EMS)
or in a non-PCI centre, the decision for choosing reperfusion strategy is based on the estimated time from STEMI diagnosis to PCI-mediated
reperfusion (wire crossing). System delay for patients alerting the EMS starts at the time of phone alert, although FMC occurs when EMS
arrives to the scene. ´denotes minutes. aPatients with fibrinolysis should be transferred to a PCI centre immediately after administration of the lytic
bolus. From: Eur Heart J. Published online August 26, 2017. doi:https://doi.org/10.1093/eurheartj/ehx393. With permission of Oxford Academic Journals,
obtained Jan 30, 2018 (License number 4278940402904)

STEMI was localized as anterior in 43.5% of cases, inferior contact, a significant median time loss of 25.6 min until
in 41.1%, and lateral in 3.8%. In 11.6% of all cases, ST- re-perfusion was noted compared with cases primarily
segment elevation was found in both anterior and inferior managed by EMS. A pre-hospital time < 30 min was
or even more segments. 81.2% of the patients were found achieved in 25.8% of all patients during the day com-
stable and normotensive, 11.3% hypotensive, and 2.9% pared to 11.6% at night (p < 0.001).
required advanced treatment due to cardiogenic shock;
4.6% suffered cardiac arrest.
Pre-hospital therapy
Pre-hospital time intervals STEMI network-specific management and pharmaco-
The majority (72%) of all EMS missions for STEMI pa- therapy algorithms are outlined in Figs. 1 and 2. In
tients occurred between 06:00 and 20:00. Time intervals accordance with the ESC flowchart, pre-hospital
were further analysed in 387/416 patients (Fig. 3). Fe- thrombolysis was attempted in 27 cases (6.5%). Tenecte-
male patients hesitated longer than male patients to call plase was administered within the first hour after onset
EMS: 67 (IQR 28–171) compared with 45 (IQR 19–120) of pain in 19 patients. Seven patients received Tenecte-
minutes, p < 0.003. Also, patients > 75 years waited lon- plase during on-going CPR, enabling return of spontan-
ger than patients < 60 years and < 45 years: 75 (IQR eous circulation on scene in 6 cases. Interestingly, EMS
121–236) compared to 43.5 (IQR 77–136) and 35.5 (IQR physicians considered pre-hospital thrombolysis indi-
46–117) minutes (Fig. 4). In 28% of all cases, a general cated in 97 additional EMS missions, but noted contra-
practitioner (GP) was involved, either at the patient’s indications in 35 patients. In 62 cases, pre-hospital
home or in the doctor’s office. When patients consulted thrombolysis was omitted based on the telephone advice
their family physician first and avoided direct EMS of the PCI centre. All 62 patients were transported
Trimmel et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2018) 26:38 Page 4 of 8

Fig. 2 Prehospital algorithm for the treatment of ACS patients as defined by the Eastern Austria STEMI Network

directly to the PCI centre, and a median FMCBT of 109 without further interventions. In 6.7% PCI was spared. In
(IQR 83–134) minutes was achieved in this cohort. patients that had received pre-hospital thrombolysis, a
rescue PCI was performed in 63% within 82 (IQR 62–144)
Primary percutaneous coronary interventions (PPCI) minutes. The remaining thrombolysed patients were
381/416 patients (91.6%) underwent PCI. Direct patient subjected to angiography within 10 days after admission.
handover in the catheter laboratory was performed in
13.7% of cases, but over 50% of all cases were admitted to Ischemia time-intervals
either an emergency ward or an intensive care unit. Median FMCBT was 94.5 (IQR 76–115) minutes by
Median and interquartile door to balloon time was 45 EMS only. When a general practitioner was involved,
(IQR 32–66) minutes. PPCI was successfully performed FMCBT increased to 120 (IQR 110–151) minutes
in 88.7%, while 4.6% underwent diagnostic angiography (p < 0.003).

Fig. 3 Timeline in STEMI patients. Legend: Critical points of time, related to the outcome of ACS patients. FMCBT = First medical contact to
balloon time; EMS = emergency medical service; DBT = door to balloon time; ACS = acute coronary syndrome
Trimmel et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2018) 26:38 Page 5 of 8

Fig. 4 Patient delay, related to age. Legend: n = 387 (93% of 416 patients with STEMI; 29 (7%) were excluded due to lack of information on the
onset of pain). Data are presented in groups reflecting the decision time: less than 2, 6, 12 or more than 12 h respectively (from onset of pain to
emergency call, logarithmic plotting). Age groups: below 45, 60, 75 years or more than 75 years, respectively. DT = Mean value of delay, specified
in minutes per age group; CI = Confidence Interval

In the patients handled primarily by EMS, the targets of transport, two were in cardiac shock or classified as
FMCBT < 120 or even better < 90 min were reached in 78 unstable by the EMS physician, respectively. Only one of
and 46% of cases; in the GP first followed by EMS cohort, the non-survivors was classified as stable during pre-
these targets were reached in 71 and 38% of cases (p < 0.05). hospital care.
The median of total ischemia time (onset of pain until
re-opening of the vessel) was 181.5 (IQR 135–256) Discussion
minutes. As mentioned above, involvement of a GP re- The European Society of Cardiology (ESC) recommends
sulted in an increased total ischemia time of 218 that a regional reperfusion strategy should be established
(IQR 155–347) minutes (p < 0.005). to maximize efficiency of STEMI patient care [9]. In this
retrospective quality control study, performance of the
Complications Eastern Austrian STEMI network was assessed over a 2-
EMS physicians had to deal with complications in 23.8%, year period. We identified two major factors prolonging
namely cardiac arrest (7%), arrhythmias (6%), cardiogenic total ischemia time, namely a significant delay between
shock (5.3%), as well as nausea, severe pain or respiratory onset of pain and EMS activation, and involvement of
problems (5.5%). In patients that had received pre-hospital general practitioners. When compared with data from
thrombolysis (N = 27), re-perfusion arrhythmias were international STEMI registries or study groups, Eastern
observed in 8 cases, and 5 patients developed cardiac Austrian time intervals as well as PCI rates are competi-
arrest. tive. Nevertheless, there is room for improvement such
Ticagrelor was administered in 317/416 patients dur- as better involvement of rescue helicopters and initiation
ing the pre-hospital phase. Two of these patients (0.63%) of night flight programs. The latter is of specific interest,
had bleeding complications: one developed a minor since 28% of STEMI cases occurred during night hours
hematoma at the radial puncture site; the other under- defined as the time between 20:00 and 06:00 and dis-
went angiography via femoral access and suffered from tances within the network might be as far as 90 km.
renal haematoma, presumably caused by the guide wire. STEMI is a predominantly male disease with a male:fe-
The latter needed transfusion of two pRBCs. male ratio of 2:1 to 3:1 [12]. Two other gender specific
differences must be noted. First, male STEMI patients
Outcome are younger when compared with female cardiac pa-
At hospital admission 8.9% of all patients were classified tients (62 compared to 70 years); and second, male
as unstable, and 0.5% (N = 2) were transported during patients activate EMS significantly earlier (45 compared
on-going CPR. Hospital outcome data was available for to 67 min). The delay before calling EMS is also import-
394 patients. Five patients (1.2%) died within the first ant in elderly patients, who might not experience the
24 h after admission, prior to or during PCI. Hospital same pain level or interpret chest pain inappropriately:
mortality was 2.8% (N = 11). Seven of the deceased pa- time from onset of pain to EMS activation was signifi-
tients had to be resuscitated on scene or during cantly longer in patients > 74 years than patients < 60
Trimmel et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2018) 26:38 Page 6 of 8

or < 45 years. Thus, creating better awareness for spe- distances will increase and may reach up to 90 km. Thus
cific symptoms is of particular importance as required employment of helicopters during night hours could
by the 2012 ESC guidelines: “Patients with chest pain contribute to reduced ischemia times [19, 20].
suggestive of MI should be directed through public The door to balloon time (DBT) has been identified to
awareness programs ...” [13]. Once EMS is dispatched, have an impact on outcome [21, 22]. The observed me-
the observed median response time is 14 min in our dian DBT of 45 min matches European standards [23],
network and might be judged appropriate in a pre- but half of all patients were still admitted at the emer-
dominantly rural environment. gency ward or intensive care unit first. Accordingly, bet-
General practitioners play an important role in pri- ter coordination and direct patient transfer to the
mary health care as gatekeepers and as first responders catheter laboratory could lead to a reduction in DTB
in rural areas. However, our data show that the 28% of times in the PCI centres. Finally, the documented me-
the STEMI patients who were first seen by their family dian total ischemia time of 181 min achieved in our
physician, either at home or in the doctor’s office, expe- network is comparable to European data derived from
rienced a delay in activation of blue light and siren EMS; Germany (239 min) [15], Hungary (223 min) [16] and
the two important time intervals, namely first medical Sweden (175 min) [14]. In the APPOSITION-III trial,
contact to balloon (FMCBT) and total ischemia time total ischemia times of 165, 270 and 360 min were
were significantly prolonged (25.6 and 38 min, respect- reported for the Netherlands, Germany and France,
ively). Thus, a median FMCBT < 120 min was achieved respectively [18].
in 78% of immediate EMS vs. 71% practitioner first pa- Besides the time-critical patient management compris-
tients. When this ratio is compared with international ing dispatch, response time, time to diagnosis, transport
FMCBT data there is room for improvement in our net- and door to balloon time (Fig. 3), early initiation and
work [12, 14–18] because mortality rates will increase quality of medical care is required. On-site coagulation
when delays cause an FMCBT > 1 h [14]. management might have an impact on outcome [11, 18].
Another option to reduce FMCBT might be a better In this regard, we consider two aspects of major import-
use of rescue helicopters for patient transport. Although ance. First, adherence to an accepted treatment algorithm,
the observed median transport times of 41 (33–55) mi- and second, communication loops with PCI centre cardi-
nutes in our network are within international ranges, ologists. We found both quality parameters adequately
only 26% of all transports were shorter than 30 min dur- fulfilled in our network. The network-specific medication
ing the daytime. This ratio further decreased to 12% at guideline, comprising unfractionated heparin, salicylic acid
night. Helicopters were dispatched in only 17% of all and Ticagrelor was successfully administered in 76% of all
cases during day, but are currently not available for patients seen by EMS (see Fig. 5). Deviations from the
night flying. Given the fact that the 3 PCI centres share guideline were justified by pre-existing patient medication
the on duty rotation during the night, transport such as warfarin. In particular, administration of 180 mg

Fig. 5 Prehospital medication, delivered by EMS. Legend: Medication delivered by EMS physicians (absolute numbers). npat = 416. ASA =
Acetylsalicylic acid, P2Y12 Inhibitors: Ticagrelor, Clopidogrel
Trimmel et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2018) 26:38 Page 7 of 8

Ticagrelor orally was feasible and safe. During the entire Conclusion
study period, no life-threatening bleeding complication In conclusion, results from the Eastern Austrian STEMI
such as intra-cerebral haemorrhage was noted. Another network shed light on the necessity of creating patient
possible life-saving intervention is the deliberate adminis- awareness in order to minimize any time loss derived by
tration of thrombolytic drugs such as Tenecteplase. The delayed EMS calls. Involvement of family physicians re-
importance of this therapeutic option is further supported sulted in prolonged FMCBT. Although PPCI rates, time
by our findings. EMS physicians successfully performed intervals and outcome rates match with international
an intravenous thrombolysis within 19 (IQR 11–27) mi- benchmarks, the efficacy of a supra-regional STEMI net-
nutes in 27 patients (6.5%). In an additional 97 missions, work with long transport distances could be improved
thrombolysis was considered but omitted. This was due to when the best transport mean is employed deliberately
contraindications in 35 patients. In the remaining 62 for every patient. Thus further evaluation of the poten-
cases, pre-hospital thrombolysis was withheld based on tial role of HEMS in STEMI networks is warranted.
the telephone advice of the PCI centre. Interestingly, only
Acknowledgments
33 of the latter 62 patients underwent PPCI within the The Medical Directors of EMS (Gabriele Zeh, M.D., Baden; Mag. Susanne
120 min time span, so that on-scene thrombolysis would Ottendorfer, M.D., Mödling, Schwechat; Günther Frank M.D., Eisenstadt,
have been justified in 29 additional patients. Nevertheless, Frauenkirchen; Robert Wagner M.D., Hainburg; Manfred Beham M.D.,
Oberwart; and the Directors of PCI centers (Franz X. Roithinger M.D., Ph.D.,
95% of all patients diagnosed with STEMI were admitted Mödling; Karl Silberbauer M.D., Ph.D., Christian Rott, M.D., Wiener Neustadt)
at one of the three PCI centres in our network, and revas- contributed to documentation and data acquisition.
cularization was attempted in 88.7%. Thus, our findings
Availability of data and materials
are similar to international data from France (87.6% PPCI, Please contact author for data requests.
12.4% thrombolysis) [24] and Germany (85.6% PPCI, 4.6%
thrombolysis) [24]. Authors’ contributions
HT concepted, initiated and designed the study, analysed and interpreted
In critical patients with life-threating arrhythmias, data, and drafted the manuscript. TB and LF helped to analyse the data and
shock or cardiac arrest, immediate and qualified medical revised the manuscript. WS contributed to data interpretation and helped to
help is critical. Our EMS personnel were able to stabilize draft and revise the manuscript. WGV participated in concept and design of
the study, data interpretation and drafting of the manuscript and critically
7/12 patients with cardiogenic shock, and to achieve re- revised the manuscript. All authors read and approved the final manuscript.
turn of spontaneous circulation in 17/19 cardiac arrest
patients. At hospital admission, 90% of all patients were Ethics approval and consent to participate
All data obtained was handled according to current data protection guidelines.
considered haemodynamically stable. The first 24 h mor- The ethical committee of the Medical University of Vienna declared the study
tality was 1.2%, and hospital mortality was 2.8%. The ob- unproblematic and granted permit (EK-ID number 1116/2016).
served mortality rate might be considered as a key
Competing interests
indicator for the efficacy of our network. Heller [25] and
The authors declare that they have no competing interests.
Schmidt [26] reported hospital mortalities of 13.9 and
14.8% respectively in patients with acute myocardial in-
Publisher’s Note
farction (AMI) in 2004–2008; Radovanovic reported Springer Nature remains neutral with regard to jurisdictional claims in
hospital mortality of 5.5% for men and 6.9% for women published maps and institutional affiliations.
for STEMI patients in 2017, enrolled in the Swiss na-
Author details
tionwide registry (AMIS Plus) [27]. Thus, there has been 1
Department of Anesthesiology, Emergency and Critical Care Medicine,
a notable general reduction in hospital mortality in Eur- General Hospital Wiener Neustadt, Corvinusring 3-5, A 2700 Wiener Neustadt,
ope during the last decades. Austria. 2Karl Landsteiner Institute of Emergency Medicine, General Hospital
Wiener Neustadt, Corvinusring 3-5, A 2700 Wiener Neustadt, Austria.
However, some limitations of our study must be noted. 3
Department of Internal Medicine II, General Hospital Wiener Neustadt,
First, this is a purely retrospective study with data de- Wiener Neustadt, Austria. 4Medical University Vienna, Vienna, Austria.
5
rived from an EMS-driven registry. Accordingly, data Department of Anesthesiology and Critical Care Medicine, AUVA Trauma
Center Salzburg, Salzburg, Austria. 6University of Stavanger, Network for
quality is strongly influenced by the documentation Medical Sciences, Stavanger, Norway. 7Paracelsus Medical University Salzburg,
quality. Second, primary cardiac arrest patients were Salzburg, Austria.
not included in this study, although STEMI or ACS
Received: 7 February 2018 Accepted: 25 April 2018
might have been the reason for cardiac arrest. To our
knowledge, cardiac arrest patients are typically not in-
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